Hipertensión pulmonar en la enfermedad pulmonar obstructiva crónica
Pulmonary hypertension in chronic obstructive pulmonary disease
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La hipertensión pulmonar (HP) es una complicación relativamente frecuente de la enfermedad pulmonar obstructiva crónica (EPOC). Su aparición en el curso clínico de la EPOC es un factor condicionante de peor pronóstico que se asocia con disminución de la sobrevida y mayor uso de recursos de salud. Aunque no hay una relación lineal bien definida, la prevalencia de HP en pacientes con EPOC aumenta a medida que es mayor el grado de obstrucción y la
severidad de la enfermedad, siendo poco frecuente en casos de EPOC leve y moderada. La HP en la EPOC es, en general, leve o moderada y pocas veces afecta la función ventricular derecha. En muchos casos no es aparente en reposo y se manifiesta con el ejercicio. La HP puede llegar a ser severa o estar "fuera de proporción" para el grado de severidad de la EPOC. En esta situación debe explorarse la posibilidad de condiciones asociadas, si bien, con
frecuencia, la única explicación final sea la EPOC. Poco se sabe de la prevalencia y el comportamiento de la HP en pacientes con EPOC residentes en alturas intermedias y grandes (>2.500 metros sobre el nivel del mar) que es una situación frecuente en Latinoamérica y Asia. La HP en EPOC no está relacionada exclusivamente con la hipoxia/hipoxemia y la hipercapnia. Los trastornos mecánicos propios de la EPOC (hiperinflación y presión alveolar) y la inflamación pueden prevalecer como causa de la lesión endotelial y la remodelación de la circulación pulmonar contribuyentes al aumento de la presión y la resistencia
vascular pulmonar. La aparición de signos de cor pulmonale indica una condición avanzada de la HP, por lo cual esta condición debe sospecharse tempranamente cuando la disnea, la hipoxemia y el deterioro de la difusión son desproporcionados para el grado de obstrucción. La confirmación de la HP se hace mediante ecocardiografía doppler y el cateterismo derecho sólo se justifica en casos individualizados. La terapia a largo plazo con oxígeno es la única intervención que ha mostrado ser eficaz temporalmente. Los vasodilatadores convencionales no producen mejoría a mediano y largo plazo y pueden empeorar las relaciones ventilación-perfusión. De la misma forma, las nuevas terapias para HP no parecen ser una opción terapéutica salvo en los casos de HP fuera de proporción" en los cuales otros factores diferentes de la EPOC podrían estar presentes. El desconocimiento del comportamiento de la HP en pacientes con EPOC residentes en alturas intermedias y grandes abre también un campo de investigación en el papel de las terapias con oxígeno y farmacológica en estas alturas.
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